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Laser prostate surgery

Urology

Holmium Laser Enucleation of the Prostate

Introduction

Holmium Laser Enucleation of the Prostate, otherwise known as HoLEP, is a surgical technique available for the treatment of urinary symptoms due to benign enlargement of the prostate (BPH). It is the only laser technique recommended by NICE (the National Institute for Health and Clinical Excellence) for the treatment of BPH in the UK and is recommended for men with prostates of any size.

History

HoLEP was developed by 2 New Zealand Urologists, Peter Gilling and Mark Fraundorfer, in the 1990’s. There are a large number of published clinical trials that support it as a new “Gold Standard” for treating BPH. HoLEP has been performed at Addenbrookes Hospital since Mr Aho (who trained with Messrs Gilling and Fraundorfer) was appointed as a consultant urologist in 2004. We are the most experienced HoLEP centre in the UK having performed more than 1000 HoLEP procedures. Addenbrookes is recognised as a centre of excellence for HoLEP. Urology teams from the UK and abroad attend our training meetings to learn how to set up and run a successful HoLEP service.

Advantages of HoLEP

HoLEP was developed to improve the effectiveness, safety and durability of surgery for BPH. The main advantages of HoLEP over Transurethral Resection of the Prostate (TURP) which has been in use for the past 50 years include:

  • More tissue removed
  • Suitable for men with prostates of any size
  • Can be used in men who have bleeding disorders or are on blood thinners (eg. Aspirin, clopidogrel and warfarin)
Overview
Prostate anatomy

Where is the Prostate and What Does it Do?

Unless affected by BPH the prostate is a walnut sized gland. It is only found in men and is a solid organ with a hollow channel running through it’s centre that is situated between the bladder and the urethra tube. Urine travels from the bladder through the channel in the prostate and into the urethra when urinating. The prostate is tiny in childhood, grows during puberty and is the only organ that continues to grow throughout life. It is this growth later in life that can cause urinary problems.
The prostate produces some of the fluid in semen. Men can live a perfectly healthy life if part or even all of the prostate is removed surgically.

Why are urinary symptoms (waterworks problems) important in men?

Urinary symptoms are the most common and bothersome symptoms affecting men beyond middle age. They may indicate a serious underlying problem and are therefore important to inform your doctor about. There are a number of potential causes for urinary symptoms in men but by far the most common is Benign Prostatic Hyperplasia (BPH).

What symptoms can be caused by BPH?

  • BPH leads to a physical growth of the prostate which may compress the prostate channel causing the urinary stream to slow, an intermittent flow (stopping and starting during urination), and straining to begin urination
  • After a while the bladder tries to compensate for the prostate blockage by becoming muscular and more powerful. This leads to the bladder becoming “unstable” with the bladder muscle contracting more frequently and forcefully than previously. This can increase the number of times you pass urine day and night and cause urgency (a sensation of having to rush to the toilet to pass urine at times).
  • Sometimes as the prostate grows it can cause blood to appear in the urine
  • If the prostate blockage prevents the bladder from emptying properly, there is an increased risk of developing urinary infections, and forming bladder stones in the pool of stagnant urine in the bladder. Rarely, if the bladder is always full, back pressure can be transmitted up to the kidneys and this can cause kidney failure.
  • In men who have a degree of prostate obstruction there may be a sudden inability to pass urine. This leads to the very painful complication of urinary retention which is treated initially by placement of a urethral catheter. In most men who experience painful urinary retention it is appropriate to consider surgery to allow successful removal of the catheter and to prevent retention from occurring again in future.

What common tests are performed to identify urinary symptoms due to BPH?

The main purpose of tests done to investigate men with urinary symptoms are to:

  1. Rule out cancer.
    This is done by testing a urine sample, performing a blood test (Prostate Specific Antigen- PSA), and examining the prostate by rectal examination.
  2. Look for evidence of prostate obstruction.
    This is done by measuring a urine flow test and checking how well the bladder has emptied by scanning it soon after passing urine.

What are the treatment options for urinary symptoms due to BPH?

  1. Lifestyle changes
    For men with minimal urinary symptoms the impact of these symptoms on their lives can be minimised by decreasing alcohol and caffeine intake and reducing fluid intake in the evening
  2. Medical treatment
    Two types of tablets are available for treating BPH:
  • Alpha blockers relax the muscle in the prostate and bladder neck to help widen the prostate channel when urinating.
  • 5-alpha reductase inhibitors shrink the prostate
  • Some plant extracts such as saw palmetto are also favoured by some men and can improve urinary symptoms
  1. Surgical treatment
    For men whose urinary symptoms are a nuisance/impair quality of life, and who either :
  • Don’t like to be on longterm medication
  • Have side effects from the medication
  • Don’t respond to the medication
  • Are bleeding from their prostate repeatedly
  • Have urinary infections due to their prostate
  • Have bladder stones
  • Have urinary retention
  • Have kidney failure due to their prostate
  • Surgery (HoLEP or TURP) may be an appropriate treatment.

BPH in numbers

  • Urinary symptoms due to BPH affect 3.2 million men in the UK.
  • Only 400,000 receive treatment despite effective treatments being readily available
Private patients

We can offer Saturday HoLEP operating lists at Addenbrookes Hospital for private patients:

What are the advantages of having my HoLEP done privately at Addenbrookes?

As the most experienced centre in the UK for HoLEP surgery, our highly skilled team will take care of you from the time that you decide to proceed with surgery until the time you are discharged from the urology service at your final clinic visit.

We have presented our HoLEP results and patient outcomes at national and international meetings and these are amongst the best in the world.

Our urology ward and operating theatres are situated in the modern Addenbrooke’s Treatment Centre which was opened in 2007 and offers state-of-the-art facilities.

For men with complex medical problems Addenbrooke’s offers the security of high quality comprehensive medical support if required.

At Addenbrooke’s we are able to offer an extremely competitive HoLEP package price for those who are paying their own fees. This is approximately half the price charged by private hospitals. We are also able to offer HoLEP to those who have medical insurance.

Waiting times for private HoLEP at Addenbrooke's can be as short as several days and are up to 1 month at the most.

Will I have a room to myself?

All efforts are made to allocate single rooms to private patients, however this cannot be guaranteed as bed allocation is dependent on clinical priority and availability.

What about MRSA?

There has been much media interest in MRSA. At Addenbrookes we are fortunate to have a modern ward that is maintained to the highest standards of cleanliness. Staff follow strict infection control policies and MRSA infection is very rare. Patients who are very unwell and have multiple procedures/catheters/intravenous lines/tubes etc, and stay for long periods of time in hospital are those most at risk of MRSA infection. Men admitted for HoLEP have none of these risk factors.

How do I arrange private HoLEP surgery at Addenbrookes?

If you live in the UK or Ireland we require either a GP or urologist referral letter with details of your PSA (if you do not have a catheter), rectal examination and dipstick urine test results. We also need a list of your current medications and a summary of your medical history. Please print the International Prostate Symptom Score, fill it out according to the instructions and bring this with you to your first appointment. If you have seen a urologist previously it would be helpful if you could provide your flow rate and bladder scan (post void residual volume) measurements as well as your estimated prostate volume

If you are an international patient please also send as much of the above information as possible.

Please send referral letters and other information to:

tevita.aho@addenbrookes.nhs.uk

OR

christof.kastner@addenbrookes.nhs.uk

OR

jim.armitage@addenbrookes.nhs.uk

OR Fax to:

+44 1223 348664

The HoLEP surgeons will assess the information you have submitted and respond to your enquiry. If deemed suitable a clinic appointment will be made to discuss HoLEP surgery and to arrange preassessment tests. A date for surgery will be booked and the Addenbrooke’s Paying Patients Office will arrange payment and admission details.

The usual length of stay (in 90% of men) is 1 night. If travelling from more than 2 hours drive away it is recommended that arrangements are made to spend 2 days in Cambridge after HoLEP before travelling home. A clinic follow up is usually booked 3 months after surgery.

For international patients it is recommended to stay a minimum of 1 week in the UK after surgery, and a check up appointment in clinic will be arranged before your departure

Terms and Conditions

Data Protection Notice

The confidentiality of patient information is of paramount concern to us. To this end, we fully comply with Data Protection Legislation and Medical Confidentiality Guidelines. Medical Information will be kept confidential. It will only be disclosed to those involved with your treatment or care, or to their agents, and, if applicable, to any person or organisation who may be responsible for meeting your treatment expenses, or their agents. Anonymised or aggregated data may be used by us for research or statistical purposes. Information may be disclosed to others with a view to preventing fraudulent or improper claims.

Terms and Conditions

  1. We will provide inpatient and outpatient care at the request of the medical practitioner who is supervising your treatment.
  2. Fees for services provided by other Consultants, pathologists and radiologists etc are additional charges made by us.
  3. If you are insured, it is advisable to check that the full costs of your treatment are covered by your insurance company prior to undergoing treatment by us.

Financial Agreement

  1. I agree to pay for the services provided, and have received details of our prices and terms of business
  2. If a third party or insurer has agreed to pay my account, I agree to pay any balance outstanding if the third party or insurer does not pay the account in full
  3. Insured Patients Only: I declare that my/the patient’s general practitioner recommended the specialist treatment and that, to the best of my knowledge and belief, the information given on this form is true and complete. I authorise Addenbrooke’s Hospital to submit claims relating to my/the patient’s treatment to my/the patient’s insurer on my/the patient’s behalf.